Business Earthquake Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Business Name

Street Address

City

State

Zip Code

Phone Number

Alternate Telephone

Fax Number

* Email Address

Building & Property Information

Property Street Address

City

State

Zip Code

Occupancy Type

Building Type

Year Built

Total Square Footage of Building

How many units are in the building?

Garage Description

How many stories is it?

What is the construction type?

What is the foundation type?

What is the nature of sub-soil?

What is the topography?

What type of roof covering?

Is the roof updated?

Yes

No

If yes, what year?

Is there any erosion in the area?

Is there any below ground parking?

Yes

No

Is there any soft first story or tuck under parking?

Yes

No

What is the distance to fire protection?

Is the business in a brush area?

Yes

No

If yes, has the brush been cleared by 250 feet from all around the building?

Yes

No

Are there smoke detectors at this location?

Yes

No

Are there fire extinguishers?

Yes

No

Are there circuit breakers?

Yes

No

Is the electrical updated?

Yes

No

How old is the heating/ air conditioning?

Has the plumbing been updated?

Yes

No

If yes, what year was the plumbing updated?

Is the plumbing copper?

Yes

No

Does the building have interior automatic fire sprinklers?

Is there a fire alarm?

Has the building been retrofitted or bolted?

Yes

No

Claims Information

Were there any losses or claims in the last 5 years?

Yes

No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company

How much are you paying now?

What is the building coverage requested?

What is the other structures coverage requested?

What is the contents property coverage requested?

What is the loss of use coverage requested?

What is the earthquake deductible?

Questions or Comments

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

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